Healthcare Provider Details

I. General information

NPI: 1407080898
Provider Name (Legal Business Name): COUNTY OF MENDOCINO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 05/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 OBSERVATORY AVE
UKIAH CA
95482-5641
US

IV. Provider business mailing address

405 OBSERVATORY AVE
UKIAH CA
95482-5641
US

V. Phone/Fax

Practice location:
  • Phone: 707-472-2607
  • Fax:
Mailing address:
  • Phone: 707-472-2607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP2400X
TaxonomyPrison Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA GUNTLEY
Title or Position: PROGRAM MANAGER
Credential:
Phone: 707-472-2607